Using public-private partnerships to

influence healthcare policy and practice

in Bangladesh

CASE STUDY

Public-Private Partnerships (PPPs)

are increasingly used in health

service delivery to coordinate

national and international efforts in

healthcare provision.

In Bangladesh, the PPP model is

being used to formalise the referral

process between Private Medical

Practitioners (PMPs) and designated

TB diagnosis centres, orientate large

workforces in garment factories and

tighten up processes used to

administer family planning services.

Key points

1. Public-private partnerships allow PMPs to

make use of free testing and prescription

services offered by the National TB Control

Programme (NTP)

2. They also allow the TB Centres and PMPs to

trace patients and monitor whether patients

complete treatment

3. Findings from our pilot study show that the

PPP was responsible for a 24.5% increase in

TB referrals by PMPs over 5 years1

4. The NTP endorsed a policy to engage the

garment sector in TB control. A Memorandum

of Understanding is now in place between

relevant stakeholders

5. We have extended the use of PPPs to family

planning services. Our initial findings show

differences in approaches, incentives, and

capacity across the public, NGO and private

sector providers.

The TB problem in Bangladesh

Prior research2 showed that all the sectors –

private medical practitioners, the NTP, hospitals

and NGOs – were working separately to tackle TB.

Private medical practitioners were working within

their own means, without any links to the national

programme, and there were no service links

between the private and public sectors for health

service delivery. The same research also showed

that TB case detection was low, and that PMPs

didn’t know they could refer patients for free

testing through the NTP. Our aim was to improve

the low referral rate.

Our approach

We met with the NTP to discuss engaging different

service providers with the national TB programme.

Together, we identified the service providers,

including PMPs. Further discussions focused on

how to develop links between the NTP and PMPs.

Case study: Using PPPs to influence healthcare policy and practice in Bangladesh www.comdis-hsd.leeds.ac.uk

We then ran a capacity assessment exercise which

involved interviewing 123 doctors, held focus

groups with doctors and NGOs, and ran workshops

at regional level with the NTP and PMPs. The

workshops focused on:

assessing the current practice used by

organisations and individuals;

their capacity for using an amended patient

referral system; and

the resources they needed to refer patients to

TB diagnosis centres.

From this, we developed a referral system that

would be appropriate to use in Bangladesh. Part of

developing a referral system involved training and

orienting the TB centres and the PMPs in using the

amended referral system. PMPs were told that

they could ask the TB Centres about their patients,

and ask patients to return to their practice.

We also negotiated with PMPs to refer patients to

designated TB Centres for free diagnosis and TB

drugs. Crucially, we didn’t change anything in the

normal practice; we simply encouraged the referral

process between PMPs and designated TB

Centres, and designed referral forms to help

administer the referral process smoothly.

Our intervention

The PPP model was used to involve PMPs in the

NTP. The model asked private doctors to refer their

patients to designated TB diagnosis Centres for

sputum testing. If the patients tested positive for

TB, they could get a prescription from their private

doctor for free drugs, also available from the TB

Centres, as part of the NTP. The scheme not only

allowed private doctors to make use of the free

testing and prescription service offered by the NTP,

but also allowed the TB Centres and private

doctors to trace patients and monitor whether

treatment was completed.

Redesigning the referral system

A new 3-part referral slip was developed and

integrated into the national programme to:

allocate a unique number to each patient;

get a record of the patient’s address and other

contact details, which was missing before;

get real-time statistics on case notification and

treatment completion; and

establish a communication loop between the

PMPs and the TB Centres that allowed doctors

to remain informed about their patients. The

last part of the 3-part referral slip was sent to

the doctor with a thank you seal.

The new forms and communication loop helped

the TB Centres and PMPs with late patient tracing.

They could see how far into the treatment patients

were, and were also able to follow up using the

unique patient number.

A baseline review of patient and

medical practitioners’ experiences Before our intervention:

patients received poor treatment;

patients often abandoned treatment after

1-2 weeks when they felt slightly better;

patients often didn’t have money to buy drugs

for long-term treatment;

private medical practitioners didn’t know that

they could refer patients to the NTP; and

patients used PMPs because they wanted di-

agnosis to be done in private: TB has a stigma

attached.

Scaling up the intervention

The scheme was piloted in 4 areas in Dhaka and

scaled up using a phased approach. PPP is now

being used in Sylhet and Chittagong divisions.

Capacity building of partners during the

research and for scale-up

Part of our approach was to consider how easy

scaling up would be for the NTP. The challenges to

scaling up the PPP model included:

thinking about the capacity of the NTP;

any policy implications on a national scale; and

encouraging the NTP to take ownership.

The close partnership with NTP, which was

nurtured using a participatory approach, allowed

us to plan for a gradual scale-up. We held

management training, and developed materials

together through piloting.

Impact on national and international policy

development

Research into using the PPP model in Bangladesh

has led to:

the NTP deciding to scale up before the official

end of the pilot (2008), as they could see the

positive effects of the PPP model early on;

guidelines and tools for PMPs to use in TB

control now being used;

detailed guidelines developed for PPP use in

Bangladesh, specifically on how to engage

PMPs in health service delivery. The research

has informed and aligns with current WHO

strategy which supports using the Public-Private

Mix model as part of their ‘engaging all

providers’ strategy3. This research also aligns

with the Bangladesh government’s PPP

priorities.4

Scaling up within the garment industry

We extended the PPP model to the workplace,

where there are huge numbers of workers in a

high TB transmission environment. Workers face

particular challenges; they are unable to attend

public healthcare facilities during working hours,

compelling them to attend PMP clinics and pay for

diagnosis and treatment. We approached the

Bangladesh Government Manufacturer Exporters

Association (BGMEA) and explained that the

national TB programme was working very well, and

could help identify and support TB patients in their

factories.

We used innovative approaches in the workplace,

for example, on-the-floor orientation and using

existing audio systems to orientate large

workforces at the factories.

Influencing policy and practice in the

garment industry

This extended PPP model is already having an

impact, for example:

TB in the workplace is high on the agenda for

WHO, informed by the PPP model in

Bangladesh;

the NTP endorsed a policy to engage the

garment sector in TB control;

a MoU was signed between the NTP and the

BGMEA, showing a growing commitment of all

key stakeholders to maintain the success of the

TB workplace programme;

a focal person was set up within the NTP to

work with the BGMEA;

guidelines and tools are ready to use for scale

up within the garment industry; and

our paper was the first of its kind on using PPP

to challenge TB in the workplace.5

Scaling up into family planning services

We are currently working in 2 urban areas in

Dhaka to develop a PPP model to increase

access to Long Acting Reversible Contraception

(LARC) for the urban poor6. Our initial findings7

show that:

there are diverse providers of LARCs across

public, NGO and PMPs;

the service charge for clients varies between

providers;

incentives to use LARCs and to refer patients

varies considerably;

processes for follow-up and recording patient

details is inconsistent across providers; and

PMPs are not always aware of referral

incentives, or have adequate knowledge of

LARCs to advise clients.

COMDIS-HSD is a Research Programme Consortium funded until 2016 by UK aid. Working with partner NGOs in 7 low and

middle income countries, we carry out research and, using our findings, provide evidence to policymakers to help them

improve the way they deliver health services to their populations. Together with our partners, our aim is to improve the quality

of prevention and care services for common diseases, as well as making these services easier for people to access, especially

in underserved populations.

Case study: Using PPPs to influence healthcare policy and practice in Bangladesh www.comdis-hsd.leeds.ac.uk

References

1. Zafar Ullah et al. (2012) Effectiveness of involving the

private medical sector in the National TB Control Pro-

gramme in Bangladesh: evidence from mixed methods.

BMJ Open, 2(6)

2. Zafar Ullah et al. (2010) Public Private Partnership for

TB Control in Bangladesh: Role of private medical prac-

titioners in the management of patients. World Medical

and Health Policy, 2(1):217-234

3. WHO. (2013) Tuberculosis (TB). Engage all care provid-

ers. [accessed 6 Feb 2013] www.who.int/tb/

careproviders/ppm/en/

4. Policy and Strategy for Public-Private Partnership, Aug

2010, Public Private Partnership Office, Prime Minis-

ter’s Office, Government of Bangladesh

Poster informing clients about LARC and sources of care,

saying: ‘Are you interested in using family planning methods

for the long-term? You have Implant - a long acting hassle

free method OR you have IUD which is hormone free - an

ideal long acting method.’

5. Zafar Ullah et al. (2012) Tuberculosis in the workplace:

developing partnerships with the garment industries in

Bangladesh. International Journal of Tuberculosis and

Lung Disease, 16(12):1637–1642

6. Assessing the effectiveness of using Public-Private Part-

nerships to improve family planning services in Bangla-

desh. Project brief. 2014. www.comdis-hsd.leeds.ac.uk

7. Farid M. Assessing access to family planning services for

the urban poor in Bangladesh. Presentation, 12th Interna-

tional Conference on Urban Health, May 2015, Bangla-

desh

For more information about our work on PPPs, contact

Dr Rumana Huque: info@arkfoundationbd.org 03/13

This project has been funded by

UK aid from the UK government